[Hemostasis and ultrasonic shears for thyroid surgery]

Randomized clinical trial of ultrasonic scissors versus conventional haemostasis to compare complications and economics after total thyroidectomy (FOThyr)

Background

The benefits of single‐use ultrasonic scissors in thyroid surgery are still debated. Although this device has been shown to reduce operating time compared with conventional haemostasis, its cost‐effectiveness has never been demonstrated. The aim of this study was to evaluate the efficacy, cost‐effectiveness and safety of ultrasonic scissors for total thyroidectomy.

Methods

This was a prospective, randomized, multicentre trial conducted at 13 hospital sites. The primary endpoint was the percentage of patients with hypocalcaemia (serum calcium level below 2 mmol/l) on day 2. Secondary endpoints included postoperative complications and costs, with calculation of incremental cost differences and cost‐effectiveness ratios.

Results

In total, 1329 patients who underwent total thyroidectomy were included in the analysis: 670 were randomized to treatment with ultrasonic scissors and 659 to conventional haemostasis. There was no difference between groups in the rate of complications, including hypocalcaemia on day 2 (19^.7 per cent in ultrasonic scissors group versus 20^.3 per cent in conventional haemostasis group; P = 0·743). Median operating times were significantly shorter with ultrasonic scissors (90 versus 100 min with conventional haemostasis; P < 0·001). Total mean(s.d.) direct costs at 6 months were €4311(1547) and €4011(1596) respectively (P < 0·001).

Conclusion

Ultrasonic scissors were no more clinically effective than conventional haemostasis, but use of these devices was more costly. Registration number: NCT01551914 (http://www.clinicaltrials.gov).

Total thyroidectomy for non-toxic multinodular goiter with versus without the use of harmonic FOCUS dissecting shears - a prospective randomized study

INTRODUCTION

Thyroidectomy is among the most commonly performed procedures involving the endocrine glands and the development of advanced surgical methods combined with a strife for performing the operation in a manner that is minimally invasive for the patient has considerably increased the need for instruments that would limit surgical trauma.

AIM

To compare of the outcomes of total thyroidectomy operations with and without the use of ultrasonic harmonic FOCUS dissecting shears.

MATERIAL AND METHODS

Eighty-two patients with a bilateral, non-toxic multinodular goiter were randomized to two groups of 41 patients each. Total thyroidectomy was performed in each patient. In the clip-ligation group (CL-G), during thyroidectomy, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic FOCUS group (HF-G), a harmonic device was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity and cost-effectiveness.

RESULTS

HF-G vs. CL-G operations were shorter (45.4 ±8.7 min vs. 64.5 ±14.2 min; p < 0.001), characterized by a lower mean blood loss (29.9 ±9.8 ml vs. 56.8 ±11.0 ml; p < 0.001) and appeared to be more cost-effective (666.2 ±37.5 EUR vs. 718.0 ±69.2 EUR; p < 0.01). No major complications were observed in both groups.

CONCLUSIONS

In total thyroidectomy operations, the harmonic FOCUS is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits include lower blood loss and a slightly decreased cost of the procedure.

Evaluation of a new ultrasonic device in thyroid surgery: comparative randomized study

BACKGROUND

Conventional techniques for hemostasis during thyroidectomy rely on knot tying, clips, and electrocoagulation. Recently, the Harmonic FOCUS Shear (Ethicon Endo-Surgery, Inc, Cincinnati, OH) was developed for thyroidectomy.

METHODS

Between December 2007 and March 2008, 62 consecutive patients (45 women, 17 men; mean age 50.9 years) undergoing thyroidectomy were randomized into 2 groups: group A, where the FOCUS was used, and group B, where electrocoagulation and clamp-and-tie technique were used.

RESULTS

The 2 groups were similar in terms of age, sex ratio, indication for surgery, and thyroid volume. Operative time was significantly shorter in group A. Significantly fewer clips and ties were used, and postoperative pain and suction balloon amount were also significantly lower in the FOCUS group. The only postoperative complication was a patient with transient hypocalcemia in group B.

CONCLUSIONS

FOCUS is a reliable and safe tool for thyroidectomy. Its utilization is associated with a shorter operative time, less blood loss, and less postoperative pain.

Novel hemostatic devices in thyroid surgery: electrothermal bipolar vessel sealing system and harmonic scalpel

Accurate and efficient hemostasis is one of the first priorities of the thyroid surgeon to prevent or minimize complications, including injury to the laryngeal nerves or parathyroid glands, perioperative hemorrhage and the potentially life-threatening hematoma. Means to prevent and control intra- or postoperative bleeding therefore remain a topic of utmost importance. Although thyroidectomy is one of the most common surgical procedures, the safest, most efficient and cost-effective way to achieve hemostasis is debated by endocrine surgeons and otorhinolaryngologists. In our opinion, there is no substitute for meticulous surgical technique and hemostasis, while experience in such operations is essential for the best outcome with the fewest complications. Ties, suture-ligations, monopolar/bipolar diathermy, clips, and hemostatic agents/sealants or tissue adhesives have been used. Over the last 10 years, innovative hemostatic devices, such as the electrothermal bipolar vessel sealing system and ultrasonically activated shears, have been developed and have been welcome adjuncts to the thyroid surgeon's armamentarium. In this review we aim to cover both novel and well-established traditional techniques of hemostasis in thyroid surgery, with specific focus on the bipolar vessel sealer and harmonic scalpel.

Minimally invasive video-assisted thyreoidectomy (MIVAT) with and without use of harmonic scalpel--a randomized study

BACKGROUND AND AIMS

Minimally invasive video-assisted thyroidectomy (MIVAT) has been used for the removal of small thyroid nodules to improve cosmetic results and diminish pain. The aim of this study was to compare the outcomes of the MIVAT operations with and without the use of an ultrasonic harmonic scalpel (HS).

PATIENTS AND METHODS

Seventy-six patients with a solitary thyroid nodule below 30 mm in diameter were randomized to two groups of 38 patients each. Unilateral thyroid lobectomy was performed in each patient. In the clip-ligation group (CL-G), during MIVAT, the superior thyroid vessels were clipped and bipolar coagulation was used to secure smaller vessels, whereas in the harmonic scalpel group (HS-G), HS was used to dissect and divide all the thyroid vessels. The statistical analysis included the mean operative time, blood loss, postoperative morbidity, scar length, cosmetic satisfaction at 1 and 6 months following surgery, and cost-effectiveness.

RESULTS

HS-G vs CL-G operations were shorter (31.4 +/- 7.7 vs 47.5 +/- 13.2 min; p < 0.001), the mean blood loss was smaller (12.9 +/- 5.7 vs 32.8 +/- 13.0 ml; p < 0.001), the mean scar length at 1 month following surgery was shorter (15.6 +/- 1.4 vs 21.5 +/- 1.9 mm; p < 0.001), and greater cosmetic satisfaction was achieved at 1 month after surgery (88.9 +/- 9.7 vs 81.9 +/- 5.4 pts; p < 0.001), but the difference became nonsignificant at 6 months postoperatively. MIVAT with HS was 20-30 euros more expensive. No major complications were observed in both groups.

CONCLUSIONS

HS in the MIVAT operations is safe and facilitates dissection, allowing for a significant decrease in operative time. Other benefits, such as lower blood loss, a scar a few millimeters shorter, or a slightly better early cosmetic result, are offered at slightly increased costs.

Apport du bistouri à ultrasons dans la reconstruction mammaire autologue par lambeau de grand dorsal

OBJECTIVE

To study the ultrasonic energy dissection technique in breast reconstruction with the autologous latissimus dorsi flap and to evaluate its effect on seroma formation and other postoperative complications.

MATERIALS AND METHODS

Prospective monocentric study, between October 2003 and April 2004, including all the patients with breast reconstruction with the autologous latissimus dorsi flap performed with Ultracision Harmonic Scalpel. The patients were followed daily for one month and postoperative drainage volume, seroma formation, local infection or other wound complications were noted.

RESULTS

Twenty-one patients, aged 47 to 62 years old, underwent breast reconstruction with this technique. The median operating time was 74 minutes. The median drainage volume was 102.2 ml/day for the first week, 58.1 ml/day for the second week, and 28.4 ml/day for the third week. The last drain was removed at the 25th day postoperatively, half of the patients were drain free at the 20th day. No blood transfusion was necessary. The postoperative complications were dehiscent scars in two patients, with a wound infection in one case. Only one patient (4.8%) required two seroma punctures.

CONCLUSION

The ultrasonic energy dissection technique in breast reconstruction was found to be an interesting alternative to the conventionnal scalpel with less seroma formation and no additional disadvantages.